Introduction

Medicaid is a mainstay of the American health care system, covering more people than any other insurance plan.^[1] In 2021, its rolls exceeded 82 million people, about a quarter of the United States population.^[2] For many of these people, this health care coverage has meant the difference between life and death.^[3] Eligibility is based on having an income below a threshold for most beneficiaries and on having specific kinds of diseases and conditions for others.^[4] For the most part, these are people who would have no other access to coverage and therefore no other source of financial resources to pay for care.^[5]

Medicaid is structured as a federal-state partnership, with the federal government providing most or a major part of the funding for every state along with overall rules for eligibility and coverage.^[6] States provide the remaining funding along with refinements of some of the rules.^[7] The federal matching share depends on a state’s average income and varies between just over 76.39% in Mississippi to 50% in New York and twelve other states.^[8] While states are not required to participate in the program, by 1982 all states and the District of Columbia had chosen to do so.^[9] Under this structure, Medicaid exemplifies federalism in a crucial area of public policy, with variation between states reflecting variations in attitudes, values, and politics.^[10]

Differences between states can be seen especially clearly in the rules for eligibility.^[11] The Medicaid program as initially structured at its enactment in 1965 only required that participating states cover four categories of low-income people: pregnant women, low-income children and their parents, those who are totally disabled, and those who are elderly, poor, and disabled.^[12] Requirements for coverage included most basic health care services.^[13] However, states could choose to add additional services, such as prescription drugs, and to broaden the scope of eligibility.^[14]

This structure has led to considerable variation in Medicaid eligibility between states and between types of beneficiaries. For example, in 2023, the income threshold for parents of dependent children in Alabama was 18% of the Federal Poverty Level (FPL) and 288% of the FPL for children in Minnesota.^[15] Variation is even more pronounced in eligibility based on specific conditions.^[16]

The Affordable Care Act (ACA) reduced the variation in eligibility criteria considerably.^[17] It required states to cover all residents whose incomes fell below 133% of the FPL without regard to categories.^[18] This meant that adults who are not in families with children could qualify. The federal government pays 90% of the incremental cost.^[19] However, participation in the expansion was made voluntary for states by a ruling of the Supreme Court in 2012,^[20] so variation remains between the jurisdictions that have accepted it, which currently number forty-one, and those that have not, which currently number ten.^[21]

Yet another layer of variation remains beyond the obvious structural elements of eligibility and coverage. To gain and maintain coverage, individuals must comply with numerous administrative requirements that vary across states.^[22] Examples include requirements for re-application at regular intervals, for face-to-face interviews as part of the application process, and for asset tests.^[23] On first blush, these may appear to be merely technical rules with minimal effect on participation. However, some of them can have a substantial impact that escapes widespread public notice.^[24]

Administrative requirements can create inequitable barriers when they are especially difficult for those with limited financial means to meet.^[25] For example, some involve production of documents that may be difficult for those with limited means to maintain and locate.^[26] Others involve in-person appearances at government offices that may necessitate taking time off from work, finding transportation, and often finding childcare.^[27] While some states have tried to mitigate these burdens by eliminating some of these requirements or mandating compliance less frequently, they remain in effect in others.^[28] Members of the general public may not notice them, but for those seeking benefits, they are all too apparent.

The importance of Medicaid administrative requirements is reflected in the churn of participation seen in several states. The Kaiser Family Foundation has estimated that nationally, 11.2% of children enrolled in Medicaid saw their coverage stop and then start again over the course of the year in 2018.^[29] The figure for adults was 12.1%.^[30] The rates were consistent in expansion and non-expansion states.^[31] Medicaid officials in California estimate that of almost 1.2 million children under the age of five who are covered by the program, about 64,000, representing about 6%, were dropped and then reenrolled the same year.^[32] The frequency of these coverage disruptions suggests that lapses in compliance with administrative requirements rather than changes in actual eligibility were responsible.

Despite these often-deleterious effects, states must impose at least some administrative rules to limit coverage to those who are truly eligible. This means ensuring that income, residency, disability, and other requirements are met and continue to be met over the course of an individual’s participation in the program. Medicaid is one of the largest items in the budgets of many states, which adds pressure on program administrators to guard against unnecessary spending.^[33] Ineligible recipients could receive benefits by falling through the cracks of the program’s bureaucracy. It is also possible that some could join the rolls through actual fraud.^[34] However, if the rules are too stringent, eligible individuals and their family members may be denied coverage because of technicalities.^[35] As the only gateway to health care for many, the result of overly stringent rules could be deadly.

Congress has been aware of the issue for some time.^[36] The ACA directed all states to simplify several administrative requirements, such as by permitting individuals to apply online, by telephone, or by mail in addition to in person.^[37] More recently, Congress went further in response to the Covid pandemic, during which lack of access to health care became especially pernicious.^[38] When patients avoided care for a Covid infection, they threatened not only their own life and health, but the wellbeing of everyone with whom they came into contact.^[39] They could thereby become an accelerator of pandemic spread.^[40] One of Congress’s remedies was to place a moratorium on Medicaid disenrollment in all states during the public health emergency (PHE) that was declared in 2020 in response to the pandemic.^[41] This was enacted as part of the Families First Coronavirus Response Act (FFCRA),^[42] as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act.^[43] That law also offered states a 6.2% increase in the federal matching rate for Medicaid funding if they dispensed with several administrative requirements for enrolling during the PHE.^[44] All states accepted the offer, which caused the program’s rolls to swell temporarily to more than 88 million.^[45]

The moratorium ended with the end of the PHE on March 31, 2023,^[46] with more than fourteen million losing coverage in the next nine months as a result.^[47] Many became ineligible when formerly imposed administrative requirements were reimposed, but the eligibility status of many others did not change.^[48] This imposed on states the task of determining who will continue to receive coverage.^[49] States also had to decide which administrative requirements to retain when there is no longer a federal financial incentive to suspend them.^[50] To do this, they had to make important policy decisions that revisit the balance between maintaining program integrity and providing lifesaving health care access for all intended beneficiaries.

Those decisions affect the wellbeing of tens of millions of people. Ill-informed decisions can have severe consequences, so well-considered policies in this seemingly technical aspect of the program are essential. Therefore, the end of the PHE represented an opportunity for states to reevaluate the policies that had been in place.

An example of the impact of the end of the PHE on one Medicaid beneficiary was described by the Philadelphia Inquirer in the story of Aisha Ahmad, age sixty, a contractor working with people who have intellectual disabilities.^[51] She was one of almost 600,000 Pennsylvania residents who were able to keep coverage during the pandemic despite being deemed ineligible during their last renewal.^[52] They represented one-fifth of all Medicaid beneficiaries in the state.^[53] As an independent contractor, she had no access to employer-sponsored health insurance and faced the possibility of going without coverage when she had to reapply.^[54] Even if she were to qualify for Medicaid coverage at that point, restrictive administrative requirements could have hindered her ability to establish it.

Part I of this Article explains the importance of Medicaid both to individual beneficiaries and to the broader health care system. Part II describes the nature of administrative requirements for Medicaid participation and the findings of empirical research on their effects. It also considers the effects of an additional burden proposed by some states in the form work requirements for maintaining coverage. Part III describes the administrative easing implemented under the PHE and the effects of its expiration. Part IV presents proposals for further reform.

I. Medicaid and the American Health Care System

The scope and impact of the Medicaid program helps to explain the broad repercussions of administrative requirements for obtaining and maintaining coverage.^[55] The program has been described as a “sleeper provision” in the 1965 legislation that also created Medicare,^[56] but it is often also called the “workhorse” of the American health care system.^[57] It is the largest program providing health care coverage for those with low incomes and is the most publicly visible component of the health care safety net.^[58] Although private employer-sponsored health insurance and Medicare cover more than 60% of the American population,^[59] they fail to reach a sizable portion, more than 100 million people.^[60] These include people who do not work for an organization that offers health benefits, are not the dependent of someone who does, or are too young for Medicare.^[61]

A. Medicaid’s Structure

1. Overall Structure

Medicare, which covers the elderly, totally disabled, and patients with end-stage renal disease (ESRD), is structured as a single federally administered program. In contrast, states play a central role in shaping and operating Medicaid within their borders.^[62] With its acceptance in every eligible jurisdiction, there are fifty-six Medicaid programs, one in each of the fifty states, the District of Columbia, and five United States territories.^[63] Medicaid is not only the largest government health care program in terms of enrollment but also among the most complex, owing in large part to the intricate federal-state relationship it creates.^[64] This complexity is compounded by its size, covering almost a quarter of the United States population.^[65] In 2022, its companion program for low-income children, the Children’s Health Insurance Program (CHIP), covered another 7 million.^[66] During the PHE, enrollment in the two programs surged by more than 25%, and in 2022, their combined spending reached $622 billion.^[67]

At the Medicaid program’s start, it, along with Medicare, was administered at the federal level by the Social Security Administration.^[68] In 1977, a new agency, the Health Care Finance Administration, renamed in 2001 the Centers for Medicare and Medicaid Services (CMS), took over this responsibility.^[69] Those who are elderly and poor can receive benefits under both Medicaid and Medicare.^[70] With Medicare enrollment exceeding 58 million people and Medicaid enrollment exceeding 83 million, CMS is responsible for the health care of close to half the population of the United States.^[71]

2. Health Care System Impact

Medicaid’s impact on the overall health care system is even broader than these numbers would suggest. ^[72] This is seen poignantly in the reduction in rates of uninsurance in states that expanded eligibility under the ACA.^[73] One study, a systematic review of seventy-seven studies of Medicaid enrollment, found that almost three-fourths of the 304 separate analyses reported in those studies found increases in overall insurance coverage after the expansion.^[74]

However, in helping financially vulnerable patients, Medicaid also helps the providers that serve them.^[75] A systematic review of studies comparing uncompensated care costs for hospitals in expansion states and non-expansion states found a reduction in the overall burden of uncompensated care of between 3.9% and 2.3% of operating costs.^[76] Savings across all states were found to total $6.2 billion.^[77] Another systematic review found that eleven of twenty-five studies that were analyzed reported positive effects of the expansion on hospital financial performance.^[78] Medicaid is also important to the finances of many other kinds of providers, including practitioners in several disciplines, providers of outpatient care, and providers of ancillary services, such as transportation and educational support.^[79] It is also the primary payer for nursing home care.^[80]

Medicaid is especially important to hospitals in reducing their burden of providing uncompensated care.^[81] It does so not only through direct reimbursement for care of patients who would otherwise lack a means of payment, but also through supplements for treating an excessive number of indigent patients, which are known as “disproportionate share” (DSH) payments.^[82] These can constitute a significant share of the amount that hospitals receive from the program and of overall program spending.^[83] They are also essential to the ability of many hospitals to provide care to lower income patients.^[84] In 2022, Medicaid programs paid a total of $17.9 billion in DSH payments nationally, with $6.4 billion coming from state funds and $11.5 billion from federal funds.^[85]

Beyond these direct benefits for providers, their more stable financial footing means not only better health care access for those in need of financial assistance but also more stable sources of care for the entire population.^[86] No one can be certain when and where they will need health care. Financial support that keeps providers in business, especially in underserved communities, offers reassurance to everyone that care is available.

Yet, Medicaid is also one of the most controversial programs.^[87] Debates have raged at the federal and state levels over its cost and over basic structural features such as eligibility and coverage.^[88] The ACA expansion brought these debates to the fore as state after state considered whether to accept it.^[89] As with controversies over many other government programs, Medicaid tends to enter the broad public consciousness mostly at times of major change, but when it does, the debates can be intense.^[90]

3. Coverage for Special Services and Populations

Starting in the 1970s, Congress extended Medicaid coverage to new kinds of beneficiaries by granting states flexibility to provide benefits in nontraditional ways.^[91] This was accomplished by permitting CMS to waive various operational requirements on states for providing benefits. These waivers are permitted primarily under two sections of the Social Security Act. Section 1115 authorizes CMS to allow experiments through demonstration programs.^[92] These may be used for testing alternative forms of payment, such as managed care and prospective payment for hospitals, and for alternative care arrangements, such as expanded access to home and community-based services (HCBS) for beneficiaries who would otherwise require institutionalization.^[93] An estimated six million people benefit from these services.^[94] Section 1915 authorizes CMS to permit implementation of changes such as these on an ongoing basis.^[95] More comprehensive waivers were authorized by section 1332 the ACA for innovative plans to expand coverage for the overall population.^[96]

HCBS waivers represent a significant part of the Medicaid program,^[97] and most are granted under Section 1915(c).^[98] The services they cover represent more than half of Medicaid spending on long-term care.^[99] Some of them permit access to HCBS for children regardless of family income.^[100] Covered services can include assistive technology, behavioral support, communication support, family and caregiver training and support, shift nursing, transportation, and physical, occupational, and speech therapy.^[101] HCBS coverage may also be available for children through Medicaid’s Early Periodic Screening, Diagnostic, and Treatment (EPSDT) program.^[102] Services covered under that program include early detection of conditions such as autism spectrum disorder (ASD) and intellectual disability and preventive care in addition to medically necessary services.^[103]

Forty-four states have waiver programs under Section 1915(c) for people with developmental disabilities.^[104] Twenty-nine of them have programs that specifically target children with ASD, although their terms vary considerably.^[105] Through them, thousands of children are able to receive care at home, including many who are in families with incomes that are otherwise too high for traditional Medicaid.^[106] Research has found waivers to be highly effective in addressing unmet needs for care.^[107] They also enable many parents of children with ASD to work outside the home.^[108] However, coverage under many waiver programs for ASD services extends only to age eighteen (twenty-one for some EPSDT services), forcing many adult patients to seek other sources of coverage for services they obtain in their homes or communities.^[109]

B. Enrollment Rules and the PHE

The CARES Act allocated $2.2 trillion to measures to offset some of the economic hardship caused by the Covid pandemic.^[110] An area of particular attention was the loss of employment-based health insurance coverage for the millions of people who were laid off by financially stressed businesses.^[111] In addition to offering states an enhanced federal matching share in return for refraining from dropping beneficiaries from the rolls, it required them to take various other measures to stabilize enrollment, including maintaining current eligibility policies.^[112] Forty-three states went further and took additional steps.^[113] These included using higher income thresholds for eligibility, implementing more flexible residency requirements, using less restrictive income and asset tests, permitting self-attestation of compliance with various eligibility criteria, extending the time to submit application materials, expanding the use of presumptive eligibility, and simplifying application forms.^[114]

The impact of these provisions is reflected in the 25% increase in Medicaid and CHIP enrollment that every state experienced after they took effect.^[115] Once again, administrative requirements proved their importance in determining the size and shape of state Medicaid programs. Its value as a tool for implementing broader policy goals to increase health care access also become more apparent.

II. The Nature of Medicaid Administrative Requirements

Given Medicaid’s size, states face the need to limit enrollment to those who truly meet eligibility criteria.^[116] Without measures to safeguard enrollment integrity, administration of the program could become unwieldy, and costs could become unsustainable. However, Medicaid faces a particular challenge in this regard, as the eligibility status of individuals changes over time.^[117] For those who qualify based on poverty, income can rise and move beneficiaries beyond the threshold for coverage.^[118] Those who qualify based on a condition subject to a waiver, such as ASD, can age out of eligibility in some states.^[119] In contrast, the status of individuals under the coverage criteria for Medicare—old age, total disability, and having end-stage renal disease —do not vary. ^[120] State Medicaid programs must, therefore, apply administrative rules to confirm eligibility on an ongoing basis.^[121]

A. General Participation Rules

Several administrative requirements have been widespread among the states.^[122] Of these, seven stand out for their potential to create barriers to participation. Face-to-face interviews as part of the enrollment process for some services may require a beneficiary to take time off from work and spend money for travel to a government office.^[123] While they help to assure state officials that the person seeking coverage is, indeed, who they purport to be, their potential for a differential impact is substantial. They may especially deter immigrants who find the enrollment process challenging.^[124]

Asset tests oblige beneficiaries seeking coverage under both Medicare and Medicaid to produce financial information beyond income information that may require time to find and compile.^[125] This could be especially difficult for some beneficiaries with limited time and means. Moreover, asset limits in most states have not kept up with inflation.^[126]

Enrollment periods of less than a year require frequent reapplication that may be time-consuming. Long application forms, which can be as long as sixteen pages, can take time to complete and may include extensive instructions in fine print.^[127] A survey of application forms in all fifty states found that on many, the wording was at a reading level of 11^th to 18^th grade, a font smaller than 12-point was used, and formatting was crowded.^[128] Citizenship requirements can block legal residents from obtaining benefits.^[129] In addition to those barriers that currently exist, some states have requested federal permission to add a substantial new one in the form of work requirements for receiving benefits that are coupled with obligations to regularly report employment status, which are discussed in section II, C, 2 infra.^[130]

In response to the potential dampening effects on enrollment of requirements such as those, several states have implemented policies aimed at mitigating their impact.^[131] Among these, seven stand out as noteworthy. Presumed eligibility places the burden on officials to find relevant information when they challenge an application.^[132] Along the same lines, self-declarations by applicants of information on age, residency, and income reduce the burden on applicants to provide documentation.^[133] Permitting Medicaid officials to rely on information in applications that have already been submitted for participation in CHIP or other social welfare programs, a process known as “express-lane eligibility,” eliminates the need for many applicants to submit information.^[134] Continuous eligibility for twelve months eliminates the need for frequent reapplication.^[135] Automatic renewal reduces that burden even further.^[136] Application and renewal online or over the telephone eliminates the need for in-person visits to a Medicaid office. Real-time decision making tells an applicant immediately whether enrollment has been accepted or whether an appeal may be necessary.^[137]

Efforts to ease several kinds of administrative barriers were accelerated by the ACA, which requires states to use a single application for Medicaid, CHIP, and subsidized coverage on ACA insurance exchanges.^[138] Other mandated measures include redeterminations of eligibility no more than once every twelve months, use of available information to facilitate redeterminations, and use of the same reporting method for changes as for initial eligibility determinations.^[139] It also encourages states to implement additional measures to lessen the burden on applicants, and several have done so.^[140] These measures appear to have been effective.^[141] Medicaid enrollment and spending increased substantially in all states after the ACA’s implementation, including in those that rejected the expansion.^[142]

B. Administrative Requirements and Special Populations

Waivers represent an invaluable source of coverage for many who have specified conditions or need specified services, and eligibility through them tends to be more stable than it is when based on income, since covered conditions tend to be lifelong.^[143] However, some waivers apply only to children, and covered individuals can face the risk of disenrollment when they age into adulthood.^[144] For some of them, coverage is no longer available if their income rises above a threshold.^[145] Others may lose coverage for which they are still qualified because of the burden of reestablishing eligibility.

C. Empirical Studies of Administrative Requirements

1. Research on Restrictive Requirements

Several studies have documented effects on enrollment of administrative requirements that make the Medicaid participation process more burdensome.^[146] While these effects are sometimes modest, they are also apparent across social welfare programs. Moreover, even when effects are modest in the aggregate, they can produce substantial consequences for affected individuals.

One study of administrative requirements across states developed an index of restrictiveness, with higher values reflecting more permissive rules.^[147] The index was found to rise consistently across states after the ACA, even in states that did not accept it.^[148] An especially large difference between states was found in the effects of administrative requirements on noncitizens.^[149]

A study of administrative requirements before implementation of the ACA expansion found that the greatest burden on applicants was created by asset tests.^[150] Smaller effects were observed for face-to-face interviews for applying and renewing enrollment and for frequent eligibility renewals.^[151] Shared applications for family members were found to have only a small effect.^[152] The authors also reported that uptake of Medicaid is higher when two factors are eased— the reporting burden on applicants and face-to-face interviews.^[153] In addition, the authors noted a significant effect from shorter application forms.^[154] Word counts in applications can vary from as few as 669 to as many as 9,085, and question counts from as few as forty-nine to as many as 248.^[155]

A major contributor to the effect of administrative requirements has been noted in the psychological stress of navigating confusing rules with uncertain outcomes.^[156] Other contributors to the stress of burdensome rules are the time needed to learn them, the time and cost of finding and producing documentation, the anxiety caused by dealing with an unfriendly bureaucracy, and the stigma of being subject to bureaucratic dictates.^[157]

Another study reported findings from a focus group with Medicaid recipients that elicited numerous comments on the onerous nature of the enrollment and renewal process.^[158] One participant called it “just really stressful” and “very challenging.”^[159] Several pointed to the amount of paperwork involved.^[160] A common reaction was that it was part of an effort “to trip you up.”^[161] An example cited by a participant was deadlines seen as unreasonably short for submitting information.^[162] Participants favored a more automatic enrollment and renewal process and suggested using applications that are unified across several safety net programs.^[163] To add to the burden, participants described difficulty obtaining assistance from agency staff, inconsistent information when staff were reached, and disrespectful treatment by staff.^[164]

Findings such as these have led to the characterization of some administrative burdens as a deliberate policy strategy to limit enrollment in social welfare programs.^[165] For several programs, a large proportion of eligible people fail to enroll or receive benefits, suggesting that extraneous factors, such as administrative burdens, depress participation.^[166] An analysis published in 2008 reported that only between 40% and 60% of those eligible for Supplemental Security Income (SSI), which supplements income for aged, poor, and disabled people, actually enrolled, only 25% of those who qualified for Medicaid received benefits, and less than 60% of those eligible for the Supplemental Nutrition Assistance Program (SNAP) enrolled.^[167] As further evidence that administrative requirements were at least partially responsible for these numbers, more than 25% of closings of welfare cases were found to be due to problems with documentation rather than eligibility.^[168] As a general matter, the authors also observed that administrative burdens tend to vary with the political party in control of a state, with lower burdens in states with Democratic control.^[169]

2. Research on Work Requirements

In 2018, sensing a receptive presidential administration, twenty-two states requested permission from CMS to implement demonstration programs for a new and more stringent type of administrative requirement.^[170] The underlying premise was that beneficiaries who are able to work should be required to do so as a condition of retaining Medicaid coverage.^[171] It was based on a perception that the availability of health coverage outside of employment reduced the incentive to hold jobs.^[172]

The proposed programs varied considerably in their details, such as the definition of old age or disability that would exempt a beneficiary from the requirement, the nature of acceptable alternatives to employment, such as community service, education, job search, and job training, the minimum number of work hours required, and penalties for noncompliance.^[173] They also differed in the frequency and method of required reporting of work status.^[174] The proposals in some states, including Michigan, Arizona, New Hampshire, and Kentucky, called for an especially stringent schedule with monthly reporting.^[175] Others were less demanding. Ohio called for reporting once within sixty days of enrollment and Indiana every December.^[176]

Ten applications were approved, but all were put on hold by litigation.^[177] However, one plan, that of Arkansas, was implemented for a time,^[178] remaining in effect for nine months before it was halted by a court.^[179] That state’s experience offers a chance to observe the effects of adding this form of administrative tightening.^[180]

The Arkansas plan took effect in June 2018, and it remained in effect until March 2019.^[181] It applied to all beneficiaries between the ages of thirty and forty-nine, unless they were pregnant or disabled.^[182] They were required to spend at least eighty hours a month at a job, job training, or community service.^[183] Online reporting of work status was required by the fifth of each month for the previous month.^[184] By February 2019, 116,229 beneficiaries had been phased into the program, which represented about half of the 238,870 Medicaid enrollees in the State.^[185]

A survey of the plan’s first six months of implementation found that 95% of the target population had already met the work requirement or one of its exceptions before it began.^[186] However, many beneficiaries were confused by the rules, unaware of them, or lacked internet access for reporting compliance.^[187] Those who were unaware represented almost 1/3, 32.9%, of the total.^[188] Of those who were notified by the State that they were out of compliance, almost half, 49.3%, were, in fact, reporting regularly.^[189] By the end 2018, 18,164 beneficiaries had lost coverage.^[190] Only 11% of them regained it during 2019.^[191]

The Kaiser Family Foundation estimated that if similar work requirements were implemented nationwide, between 1.4 and 4.0 million Medicaid beneficiaries would lose coverage.^[192] Between 77% and 83% of them would lose it for failure to report their work status or an exemption, rather than for failure to meet the requirement.^[193] Moreover, a report by the Commonwealth Fund looking at broader effects of work requirements on the health care system estimated that hospitals in states that implement them could lose as much as 21% of their Medicaid revenues, uncompensated care costs could increase by as much as 133%, and operating margins could decrease by more than 2%.^[194]

The Arkansas experience shows that work reporting rules can have a substantial effect in pruning Medicaid rolls that dwarfs actual noncompliance.^[195] The Kaiser Family Foundation analysis indicated that this would have been true for all of the proposed state work requirement plans had they gone into effect.^[196] This suggests that the addition of a new administrative barrier to enrollment, rather than an actual desire to put beneficiaries to work, was one of the major motivators for these plans. It also suggests that work reporting rules could be more effective at limiting enrollment than explicit tightening of eligibility criteria, which might violate the ACA or federal regulations if they were too extreme. Moreover, it is questionable whether states would be willing to bear the cost of administering work requirements if these rules only served to disenroll those who truly failed to comply.

Despite Arkansas’s experience, Georgia received approval from CMS for a waiver to permit the imposition of work requirements on a demonstration basis for three years.^[197] The requirements apply to a new category of Medicaid enrollees who were otherwise ineligible for coverage.^[198] The waiver had originally been approved by the Trump administration, but the approval was subsequently cancelled by the Biden administration.^[199] Its implementation followed a federal district court decision overruling the cancellation.^[200]

Georgia’s plan requires Medicaid enrollees in the new category to complete at least eighty hours of work, education, job training, or community service each month.^[201] It includes those between the ages of eighteen and sixty-four who earn less than 100% of the FPL and who are not otherwise eligible for coverage.^[202] Georgia has not implemented the ACA expansion, so coverage does not automatically extend to all those earning up to 133% of the FPL.^[203] The plan was estimated to add about 50,000 new beneficiaries to Medicaid rolls within two years and eventually to add about 100,000 of the 345,000 people who are eligible for it.^[204]

Enrollees in the plan have to certify their work status every month through an online portal.^[205] Those who earn more than 50% of the FPL are required to pay a monthly premium of between seven and eleven dollars.^[206] After three months of nonpayment, they lose coverage.^[207]

Critics of the plan predicted that the reporting requirement would discourage many people from participating.^[208] While a limited number of exceptions are permitted, the need for childcare is not among them, which can make it difficult for many of those who are eligible to participate.^[209] Critics have also predicted that with the process of verifying compliance, the plan will cost the state more than simply expanding Medicaid under the ACA.^[210]

3. Research on Administrative Easing

Studies of administrative changes that ease enrollment point to several that have been effective in increasing it, although with varying levels of success. One study found that the transition of the Women Infants Children (WIC) nutrition program from paper vouchers to electronic benefits in 2010 was associated with an increase of 7.78% in participation in the thirty-six states that made the change.^[211] Another examined express-lane eligibility and found an increase of between 4.0% and 7.3% in combined enrollment in Medicaid and CHIP in states that implemented it.^[212]

An especially large effect was found for automatic enrollment in Medicaid and automatic retention for ACA Marketplace plans.^[213] Automatic enrollment adds people to the Medicaid rolls even when their application is only partially complete. It was found to be associated with an increase in total enrollment of between 30% and 50%.^[214]

Research has also found a substantial effect for real-time decision making, in which determinations are made at the time of application.^[215] It was associated with an increase in enrollment of 9% for children and 12% for adults.^[216] The authors of this study found that rule reductions overall were associated with increased enrollment over the ten-year period from 2008 to 2017.^[217] They observed that while many of the rules had been justified as fraud reduction measures, their major effect was to deny participation to eligible individuals.^[218] The authors also found that the effect on enrollment of easing the rules was due not solely to the barriers they created but also to a reduction in the cognitive stress of compliance.^[219]

A 2013 study confirmed an impact, although small, of twelve-month continuous enrollment.^[220] The CHIP Reauthorization Act of 2009 offered this option to states, and it was implemented in seven of them.^[221] It was associated with an increase of 1.8% in the length of time that children remained in the program.^[222] A recent analysis by the Kaiser Family Foundation found that disenrollment in states with twelve-month continuous enrollment policies increased between month twelve, when the automatic retention period ended, and month fifteen, after it had ended, from 11.8% to 29.2%, suggesting that the protection provided by continuous enrollment was considerable.^[223]

A total of twenty-three states have implemented twelve-month continuous eligibility for children regardless of income variation, and a few states, including Oregon, Washington and New Mexico, extend it for even longer.^[224] New York implemented a plan to extend the eligibility period for all populations for a full year under a Section 1115 demonstration waiver that produced substantial results.^[225] The share of people with continuous enrollment increased from 53% to 72%.^[226] Most of those who benefited from the extension were relatively healthy, so the increase in Medicaid spending was modest - in the range of 2.5% to 3.1%.^[227]

4. Research on Coverage for Special Populations

Medicaid is the largest payer for mental health services, and it therefore provides crucial financial support for many patients with behavioral conditions.^[228] It is also especially important for children, so for them, attrition in enrollment is especially concerning.^[229] In one study, 27.7% of children enrolled in Medicaid and CHIP were found to no longer be enrolled twelve months later.^[230] Almost half of them, 45.4%, appeared to remain eligible for coverage and had no other insurance.^[231]

Studies examining trends in Medicaid enrollment have found that transition-age youth and young adults with ASD - those who are moving from pediatric care to adult care - are at particular risk of disenrollment from Medicaid, with many losing access as they age into adulthood.^[232] One study found that more than one in four beneficiaries with ASD lost coverage when they reached age eighteen, and fewer than half subsequently regained it.^[233] A similar pattern was found for beneficiaries with intellectual disability.^[234]

Even for children without conditions that qualify for special coverage, interruptions in Medicaid participation are common.^[235] These tend to be short, and their frequency varies between states, but they can be disruptive to ongoing treatments.^[236] Lack of health insurance is a major determinant of having unmet medical needs.^[237] Young adults with special health care needs who are uninsured are more than twice as likely as those who have insurance to forgo filling prescriptions or receiving other kinds of care.^[238]

III. Administrative Requirements After the End of the COVID Public Health Emergency

With the end of the PHE, many of the measures that maintained enrollment for millions of people, in particular the moratorium on disenrollment, expired.^[239] The enhanced federal matching share for easing administrative requirements ended in the calendar quarter following the PHE’s expiration, and CMS gave states up to fourteen months to return to pre-PHE eligibility standards.^[240] With these steps, Medicaid was transformed back into a program that looked very different in fundamental ways than it did during the PHE.^[241]

Forty-six states implemented measures to ease the transition.^[242] As an initial matter, all of them attempted to update beneficiary mailing addresses.^[243] Forty-three planned to take twelve to fourteen months to process renewals rather than rushing them,^[244] and twenty-six increased staff to process them.^[245]

However, there are several aspects of the unwinding of PHE protections that pose particular challenges.^[246] Among them is transitioning those who are no longer eligible for Medicaid and CHIP to ACA Marketplace plans when they qualify for premium subsidies.^[247] Since beneficiaries did not go through the renewal process during the PHE, the process of reevaluating the circumstances of all of them and determining which coverage they may qualify for – Medicaid, CHIP, ACA or none – could take up to a year for some states to complete.^[248]

A few states used the occasion to loosen administrative burdens on a long-term basis.^[249] Oregon and Massachusetts have received approval from CMS for demonstration projects to keep children on Medicaid until age six without any renewal action needed by their parents.^[250] Oregon’s plan became effective with the end of the PHE and guarantees enrollment from birth to age six regardless of changes in a family’s income.^[251] That State estimates that the policy will benefit more than 51,000 children.^[252] It, along with Massachusetts, also has plans to expand covered benefits to include health-related social needs, such as housing and food assistance.^[253] Massachusetts will also provide continuous coverage under Medicaid and CHIP for people in especially needy circumstances—twelve months after release from a correctional facility and twenty-four months for those with a confirmed status of chronic homelessness.^[254]

The expiration of continuous enrollment under the PHE has had significant effects, with more than thirteen million people losing coverage nationwide just within five months of its effective date.^[255] In states that reported disenrollment statistics, more than a third, 34%, of those with a completed renewal were disenrolled.^[256] This is consistent with predictions made before the end of the PHE that close to 16 million Medicaid beneficiaries would lose coverage by the time eligibility redeterminations are complete.^[257] Among those predicted to be disenrolled are almost 5.3 million children, almost four million of whom will remain eligible but lose coverage for failing to comply with administrative requirements.^[258] Many of those who lose Medicaid coverage are eligible for subsidized coverage on the ACA Marketplaces, but the premiums for this coverage may still be too high for some of them to afford.^[259] As a result, Medicaid enrollment is on track to return to its pre-PHE levels along with the churn of people in and out of the program as their eligibility changes. Administrative requirements consequently take on renewed importance in shaping the size of the program.

Behind the national numbers is tremendous variation between states.^[260] During the eight months after the end of continuous enrollment, 62% of beneficiaries with completed determinations were disenrolled in Texas, while only 10% were disenrolled in Maine.^[261] There is similarly wide variation in disenrollment of children. In the sixteen states that reported disenrollments by age, 37% overall were of children, with the proportion varying from 61% in Texas and 19% in Massachusetts.^[262] Clearly, differences in disenrollment practices between states have had a considerable effect.

State variation is also evident in the proportion of beneficiaries who lost Medicaid coverage during the eight months after the end of continuous enrollment for procedural reasons rather than actual determinations of lack of eligibility. Nationally, the figure was 71%.^[263] It varied from 94% in New Mexico to 13% in Illinois.^[264] However, in most cases of procedural disenrollment, there is no definitive determination of eligibility, leaving the door open for reconsideration.^[265]

Variation in rates of disenrollment does not necessarily reflect the effects of formal state policies. Procedural disenrollment may occur when a beneficiary has moved and does not receive a renewal notice or does not understand the steps to be taken to maintain coverage.^[266] It may also result from difficulties in communicating with Medicaid offices.^[267] Nevertheless, the large number of disenrollments for procedural reasons raises concerns that many people who remain eligible for Medicaid are losing coverage merely for inadequate paperwork.^[268]

To address logistical lapses such as these, a number of states have renewed coverage for some beneficiaries on an ex parte basis in which state officials act without waiting for the beneficiaries to submit paperwork.^[269] As with other aspects of post-PHE redeterminations, states vary considerably in the use of this practice.^[270] Most of those that use it only apply it to those whose eligibility is based on income, with rates of use ranging from less than 25% to more than 50%.^[271] A smaller number of states use it for those whose eligibility is based on other factors, such as disability.^[272]

CMS took a number of steps to try to reduce the high rates of procedural disenrollments in some states and increase national consistency in enrollment practices.^[273] These included a letter to all state Medicaid directors describing practices that violate federal regulations and suggesting practices that can reduce disenrollment, such as ex parte reenrollment.^[274] CMS also published a comprehensive list of strategies designed to reduce disenrollments^[275] and proposed rules to streamline eligibility and enrollment determinations nationally on an ongoing basis.^[276]

It is possible that state and federal initiatives such as these to streamline enrollment redeterminations after the end of the PHE will have a longer-term effect and produce a program with fewer administrative barriers, at least in some states. At the same time, a number of states will undoubtedly continue to experiment with different approaches to reducing the churn of beneficiaries. The experience with disenrollment after the end of the PHE has highlighted the importance of administrative rules in determining access to Medicaid coverage. That experience may help guide states in refining their programs in the interest of strengthening and stabilizing health care access for the millions of people who rely on Medicaid to provide it.

IV. Avenues for Further Reform

Both empirical research and recent experience have helped to identify several levers that can be effective at counteracting the deleterious effects of administrative requirements, including express-lane eligibility, acceptance of partial applications, and real-time eligibility determinations. Continuous enrollment of twelve months has demonstrated particular effectiveness.^[277] Nevertheless, there are a number of reforms that could go further. This section proposes three.

To be maximally effective, these proposed reforms would be implemented on a national basis. However, in the absence of action at the federal level, which would be politically problematic, many states could implement them on their own. An advantage of state-by-state implementation is the opportunity it creates for natural experiments that lead to a deeper understanding of the relationship between administrative requirements and Medicaid participation. Section 1115 waivers could provide flexibility to experiment with modifications of administrative rules that conflict with federal regulations.^[278] For more substantial reforms, waivers under §1332 of the ACA could provide additional flexibility,^[279] by offering latitude to implement reforms that transform states’ health insurance and health care delivery systems.^[280]

A. Automatic Enrollment Based on Tax Returns

Americans who meet income thresholds must file a tax return annually with the federal government or be covered as a dependent under someone else’s.^[281] The thresholds for filing vary based on age and marital status, ranging in 2021 from $12,550 for single individuals under age sixty-five to $27,800 for married individuals filing jointly with a spouse.^[282] These threshold amounts are close to or slightly below the FPL.^[283] This means that many who qualify for Medicaid, in particular those who live in states that have accepted the ACA Medicaid expansion, would still have to file. All but nine states also collect income tax,^[284] and many of them require the filing of annual returns.^[285] These filings, therefore, provide information on the eligibility of many individuals for Medicaid, without their having to apply.

Rather than placing the burden on individuals whose income is low enough to qualify, governments could enroll them automatically based on their tax returns.^[286] Since tax filings often contain information on entire families, automatic enrollment could apply to other family members as well. There would be no need for eligible beneficiaries to meet any of the administrative requirements for applying for coverage. Eligibility could be reassessed each year when new returns are filed. Those who no longer qualify for Medicaid could be automatically transitioned to a subsidized plan on an ACA exchange, if their income qualifies them for a policy with an effective premium of zero.^[287]

Automatic enrollment based on tax filings need not prevent individuals from obtaining other coverage, through an employer or elsewhere, if they wish. However, they would be pre-enrolled in Medicaid as a backup in case that coverage lapses or is terminated. Rather than experiencing a period of uninsurance, Medicaid would cover them instantly, without bureaucratic delay and the possibility of disrupting ongoing care.

There are, of course, limitations to this approach. It would not reach individuals who do not file tax returns. In states without an income tax or that do not require filing a return, access to federal returns would be needed. This would require coordination with the federal government that might face logistical challenges. It would also fail to reach many of those who are eligible under a waiver or because they are totally disabled. Nevertheless, it could reach a substantial number of people who either do not know they are eligible or are deterred from enrolling by administrative barriers.

B. Automatic Enrollment Based on Participation in Other Safety Net Programs

Express-lane eligibility, which enables Medicaid officials to use application information submitted for another safety net program, has been shown to be among the more effective measures to expand participation.^[288] It lets applicants navigate the enrollment process only once.^[289] The concept could be taken one step further by making it automatic for all safety net programs. If an individual is approved for one means-tested program, such as SNAP, WIC, or SSI, notification could be sent routinely to the state’s Medicaid agency without additional action by the applicant.^[290] As with the proposal for automatic enrollment based on tax filings, if Medicaid enrollment results, it would not have to preclude coverage under an employment-based policy or other means, if the beneficiary saw that as preferable.^[291] However, Medicaid would be available without delay, if needed.^[292]

Among limitations, this approach would not reach individuals who do not participate in another safety net program. As with the proposal for using tax returns to trigger enrollment, it would also fail to reach many who are eligible for Medicaid for a reason other than low income. However, if an individual qualified for another program because of medical need rather than income, their information could still be shared with the state’s Medicaid program to assess whether they would be eligible for coverage if they wanted it.

C. Automatic Transition Between Medicaid and ACA Marketplace Plans

The Massachusetts process for automatically switching individuals insured through an ACA Marketplace plan to a zero-premium plan, if they fall behind in premium payments under another plan, could be extended to Medicaid.^[293] However, many beneficiaries who lose Medicaid coverage because of an increase in income are still eligible for subsidized coverage under the ACA.^[294] Many of them may be unaware of the availability of this alternative. The program in Massachusetts was associated with a substantial reduction in coverage loss.^[295]

This approach could also automatically switch beneficiaries into Medicaid, if they are eligible, and lose eligibility for a subsidy for an ACA plan or for another public program.^[296] As under express-lane eligibility, eligibility information would be shared between programs.^[297] In essence, the state would treat these different forms of subsidized coverage as part of an integrated continuum taking the burden off the beneficiary to initiate the switch. Those who are unaware of the possibility of switching or of administrative requirements for doing so would thereby maintain continuous coverage in one form or another.

Among the limitations of this approach are that many ACA plans have more coverage restrictions than Medicaid. These include deductibles and copayments that have risen steadily since the program began,^[298] narrower networks of providers,^[299] and for some plans, fewer covered benefits.^[300] However, automatic switching ensures that at least a minimum level of coverage is provided without interruption.

Conclusion

Stabilizing Medicaid enrollment for eligible beneficiaries could save countless lives by assuring ongoing health care coverage for millions who would otherwise be locked out by the cost. It would also reinforce Medicaid’s role in supporting the overall health care system and thereby provide reassurance to millions who never contemplated becoming Medicaid recipients that a stable system of care is available when they need it. Many of the administrative requirements that create barriers to enrollment may have been prompted by a desire to limit the program’s cost, but they impose a substantial human cost that calls into question any financial savings.^[301]

Beyond providing these benefits in health and wellbeing, Medicaid also enhances society in a way that may be even more fundamental. Assisting those in need and ensuring more equitable access to a lifesaving service are essential elements of a just society.^[302] Medicaid’s creation rested in part on respect for the ethical principle of justice.^[303] Living in a society that treats people fairly and provides everyone an equal chance at economic comfort and physical wellbeing serves to solidify its moral underpinning and thereby its cohesiveness.

Debates over federal and state policy to expand health care coverage will almost certainly be with us for the foreseeable future. Health care is, after all, extremely expensive and relentlessly becoming more so.^[304] It will perennially compete with other needs in the allocation of tax dollars and personal spending. As a result, Medicaid, which has more enrollees than any other public health insurance program, will always be part of these debates.

In weighing the size and cost of Medicaid, it is important to bear in mind the program’s outsized influence on the overall health care system. A strong and stable program that includes as many eligible people as possible can produce benefits that ripple throughout American health care. Explicit expansion of eligibility, as under the ACA, has played a central part in reinforcing that role. Taming the devil in the details of bureaucratic rules, both those that inadvertently create barriers to participation and those that limit participation deliberately, is no less important.

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1. See Medicaid: A Primer on America’s Biggest Health Insurance Program, Blue Cross Blue Shield (April 19, 2017), https://www.bcbs.com/the-health-of-america/articles/medicaid-primer-americas-biggest-health-insurance-program.

2. Ctrs. For Medicaid and Medicaid Servs., May 2021 Medicaid and CHIP Enrollment Trends (last visited May 2021), https://www.medicaid.gov/sites/default/files/2021-10/may-2021-medicaid-chip-enrollment-trend-snapshot.pdf.

3. See David Frank, Why Medicaid is a Life and Death Issue, AARP (June 30, 2017), https://www.aarp.org/politics-society/advocacy/info-2017/protect-patients-first-from-medicaid-cuts.html.

4. See Medicaid Eligibility, Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/index.html (last visited Sept. 9, 2023).

5. Robin Rudowitz et al., 10 Things to Know About Medicaid, Kaiser Fam. Found. (June 30, 2023), https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/.

6. See Financial Management, Medicaid.gov, https://www.medicaid.gov/medicaid/financial-management/index.html#:~:text=The Medicaid program is jointly,Medical Assistance Percentage (last visited Dec. 24, 2023); see also Social Security Amendments of 1965, Pub. L. No. 89-97, 79 Stat. 286 (1965).

7. See Financial Management, supra note 6.

8. Matching Rates, Medicaid and CHIP Payment and Access Comm’n, https://www.macpac.gov/subtopic/matching-rates/ (last visited Dec. 24, 2023).

9. C. Brecher, Medicaid Comes to Arizona: A First-Year Report on AHCCCS, 9 J. Health Pol. Pol’y L. 411, 411 (1984); In addition, five American territories have implemented Medicaid programs – American Samoa, the Commonwealth of the Northern Mariana Islands, Guan, Puerto Rico, and the U.S. Virgin Islands. Medicaid and CHIP Payment and Access Comm’n, Medicaid and Chip in the Territories 1 (2021).

10. Gideon Lukens, State Variation in Health Care Spending and the Politics of State Medicaid Policy, 39 J. Health Pol. Pol’y L. 1213, 1213-15 (2014).

11. See Program History, Medicaid.gov, https://www.medicaid.gov/about-us/program-history/index.html (last visited Dec. 24, 2023).

12. History, CMS.gov, https://www.cms.gov/About-CMS/Agency-Information/History (last visited Dec. 24, 2023).

13. Medicaid: An Overview, Cong. Rsch. Serv. 12 (2023), https://crsreports.congress.gov/product/pdf/R/R43357 (“The traditional Medicaid program requires states to cover a wide array of mandatory services (e.g., inpatient hospital care, lab and x-ray services, physician care, nursing facility services for individuals aged 21 and older.)”)

14. Id.

15. Medicaid in Alabama, Kaiser Fam. Found. (June 2023), https://files.kff.org/attachment/fact-sheet-medicaid-state-AL; Medicaid in Minnesota, Kaiser Fam. Found. (June 2023), https://files.kff.org/attachment/fact-sheet-medicaid-state-MN.

16. See Medicaid Eligibility, supra note 4.

17. Patient Protection and Affordable Care Act, Pub. L. 111-148, 124 Stat. 119 (as amended 2010).

18. Overview of the Affordable Care Act and Medicaid, Medicaid and CHIP Payment and Access Comm’n, https://www.macpac.gov/subtopic/overview-of-the-affordable-care-act-and-medicaid/ (last visited Dec. 21, 2023). The ACA also excludes 5% of income in determining eligibility, making the effective threshold 138% of FPL. Id.

19. State and Federal Spending Under the ACA, Medicaid and CHIP Payment and Access Comm’n, https://www.macpac.gov/subtopic/state-and-federal-spending-under-the-aca/. The rate was 100% through the end of 2016, and it declined slightly each year to reach 90% in 2020. Id.

20. Nat’l Fed’n of Indep. Bus. v. Sebelius, 567 U.S. 519, 588 (2012). The decision found that the expansion itself is constitutional but that a provision denying all Medicaid funding to states that do not accept it is not. Id. Therefore, states could choose to decline to participate in the expansion while still receiving federal funding for their preexisting Medicaid programs. Id.

21. Status of State Medicaid Expansion Decisions: Interactive Map, Kaiser Fam. Found. (Dec. 1, 2023), https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

22. Bradley Corallo et al., Medicaid Enrollment Churn and Implications for Continuous Coverage Policies, Kaiser Fam. Found. (Dec. 14, 2021), https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-churn-and-implications-for-continuous-coverage-policies/.

23. Renew Your Medicaid or CHIP Coverage, Medicaid.gov, https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/renew-your-medicaid-or-chip-coverage/index.html (last visited Dec. 21, 2023); Leslie Heagy, Medicaid and F2F: The Day has Officially Arrived, Healthcare Provider Sols., https://healthcareprovidersolutions.com/medicaid-f2f-day-officially-arrived/ (last visited Dec. 21, 2023); Ashley Huntsberry-Lett, Asset Limits for Medicaid Eligibility, AgingCare, https://www.agingcare.com/articles/asset-limits-to-qualify-for-medicaid-141681.htm (last visited Dec. 21, 2023).

24. Recent Medicaid/CHIP Enrollment Declines and Barriers to Maintaining Coverage, Kaiser Fam. Found. (Sept. 24, 2019), https://www.kff.org/medicaid/issue-brief/recent-medicaid-chip-enrollment-declines-and-barriers-to-maintaining-coverage/.

25. Judith Soloman, Medicaid: Compliance With Eligibility Requirements (Oct. 30, 2019), https://www.cbpp.org/research/health/medicaid-compliance-with-eligibility-requirements.

26. Id.

27. See Tricia Brooks et al., Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings From a 50-State Survey. Kaiser Fam. Found. (Mar. 26, 2020), https://www.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey-enrollment-and-renewal-processes/.

28. As discussed infra, these include continuous eligibility for twelve months and use of enrollment information submitted by beneficiaries for participation in other social welfare programs.

29. Corallo et al., supra note 22.

30. Id.

31. Id.

32. Phil Galewitz, Stopping the Churn: Why Some States Want to Guarantee Medicaid Coverage From Birth to Age 6, Kaiser Health News (Nov. 10, 2022), https://khn.org/news/article/churn-states-guarantee-medicaid-children/.

33. Medicaid’s Share of State Budgets, Medicaid and CHIP Payment and Access Comm’n, https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/ (last visited Dec. 21, 2023).

34. See Jen Fifield, What happens when states go hunting for Medicaid fraud, Pub. Broadcasting Serv. (May 24, 2017, 3:59 PM), https://www.pbs.org/newshour/nation/happens-states-go-hunting-medicaid-fraud.

35. See Alice Burns et al., 5 Things to Know: A Look at the Proposed Medicaid Enrollment Eligibility & Enrollment Rule, Kaiser Fam. Found. (Sept. 30, 2023), https://www.kff.org/medicaid/issue-brief/5-things-to-know-a-look-at-the-proposed-medicaid-eligibility-enrollment-rule/.

36. See Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. 17,144 (March 23, 2012) (to be codified at 42 CFR pts. 431, 435, 457) (providing example Centers for Medicare & Medicaid Services).

37. Id. at 17,208.

38. See David Blumenthal et al., Covid-19 – Implications for the Health Care System, 383 N Engl. J Med. 1483, 1483 (2020), https://www.nejm.org/doi/full/10.1056/NEJMsb2021088.

39. Isolation and Precautions for People With COVID-19, Ctrs. for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html (May 11, 2023).

40. See Megan Leonhardt. Several Major Factors Affect Covid-19 Spread Among Minority and Lower-Income Communities, CNBC (Jan. 12, 2021, 10:00 AM), https://www.cnbc.com/2021/01/12/factors-affecting-covid-19-spread-among-lower-income-communities.html.

41. The PHE was enacted under the Public Health Service Act, 42 U.S.C. Ch. 6A.

42. Families First Coronavirus Response Act, Pub. L. 116-127, 134 Stat. 178 (2020).

43. CARES Act, Pub. L. 116-136, 134 Stat. 281 (2020).

44. Ctrs. for Medicare & Medicaid Servs., COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies (2021), https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf; see also Sara Rosenbaum et al., Winding Down Continuous Enrollment for Medicaid Beneficiaries When the Public Health Emergency Ends, The Commonwealth Fund (Jan. 7, 2021), https://www.commonwealthfund.org/publications/issue-briefs/2021/jan/winding-down-enrollment-medicaid-health-emergency-ends.

45. Sept. 2023 Medicaid & CHIP Enrollment Data Highlights, Ctrs. for Medicare & Medicaid Servs., https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html (last visited Jan. 11, 2024).

46. Medicaid Enrollment and Uniwinding Tracker, Kaiser Fam. Found. (Jan. 9, 2024), https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/; Consolidated Appropriations Act of 2023, Pub. L. 117-328, 136 Stat. 4459 (2023). The Consolidated Appropriations Act of 2023 severed as the link between the disenrollment moratorium under the FFCRA and the PHE. Id.

47. Medicaid Enrollment and Uniwinding Tracker, Kaiser Fam. Found. (Dec. 1, 2023), https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/?_hsmi=274164629&_hsenc=p2ANqtz-9E9pTV_54IuW2pMyp9RVmROneCg0wpeJde4qetvHyF6VI8D1ehnd_tSoOecO1me_sa9p9TSEjCuZz0mGxsWtNDnJePCQ (source is subject to regular updating); see also Megan Messerly. Biden Administration Warns States as Millions Lose Medicaid. Politico, https://www.politico.com/news/2023/08/10/biden-administration-states-medicaid-00110686 (Aug. 10, 2023, 6:15 PM).

48. William L. Schpero & Chima D. Ndumele, JAMA Health F., Medicaid Disenrollment After the COVID-19 Pandemic: Avoiding a New Crisis 1 (2022), https://jamanetwork.com/journals/jama-health-forum/fullarticle/2788765.

49. Sara Rosenbau et al., Winding Down Continuous Enrollment for Medicaid Beneficiaries When the Public Health Emergency Ends, The Commonwealth Fund (Jan. 7, 2021), https://www.commonwealthfund.org/publications/issue-briefs/2021/jan/winding-down-enrollment-medicaid-health-emergency-ends.

50. Schpero & Ndumele, supra note 48, at 2.

51. Harold Brubaker, Thousands of Philadelphians must resume applying annually for Medicaid starting in April, Philadelphia Inquirer (Jan. 14, 2023, 3:09 PM), https://www.inquirer.com/business/health/medicaid-covid-19-pennsylvania-redetermination-20230114.html.

52. Id.

53. See id.

54. Id.

55. Background on Medicaid can be found in Policy Basics: Introduction to Medicaid, Ctr. on Budget and Pol’y Priorities, https://www.cbpp.org/research/health/introduction-to-medicaid (Apr. 14, 2020).

56. Social Security Amendments of 1965, Pub. L. 89-97, 79 Stats. 286 (1965); Sydney D. Watson, Forward to The Struggle for the Soul of Medicaid, 13 Journal of Health Law & Policy 1 (2019).

57. Watson, supra note 56, at 1.

58. Julia Paradise, Medicaid Moving Forward, Kaiser Fam. Found. (Mar. 9, 2015), https://www.kff.org/health-reform/issue-brief/medicaid-moving-forward/.

59. Health Insurance Coverage of the Total Population, Kaiser Fam. Found., https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel={“colId”:“Location”,“sort”:“asc”} (last visited Dec. 21, 2023).

60. Id.; Ctrs. for Medicare & Medicaid Servs., May 2022 Medicaid and CHIP Enrollment Trends Snapshot PINCITE (2022) [hereinafter May 2022 Snapshot].

61. Jennifer Tolbert et al., Key Facts about the Uninsured Population, Kaiser Fam. Found. (Dec. 19, 2022), https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.

62. See Julia Paradise et al., Kaiser Fam. Found, Medicaid at 50 1 (2015), https://files.kff.org/attachment/report-medicaid-at-50.

63. State Profiles. Ctrs. for Medicare & Medicaid Services, https://www.medicaid.gov/state-overviews/state-profiles/index.html (last visited Dec. 21, 2023). States pay a portion of the cost that varies between 27%-50%. Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the Children’s Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2020 Through September 30, 2021, 84 Fed. Reg. 66,204, 66,205–06 (Dec. 3, 2019).

64. Using Medicaid is Complicated: The Hurts People With Disabilities. The Arc (Jan. 11, 2023), https://thearc.org/blog/using-medicaid-is-complicated-that-hurts-people-with-disabilities/.

65. May 2022 Snapshot, supra note 60, at 5.

66. Id. at 3.

67. See Medicaid, Cong. Budget office Baseline Projections (2023), https://www.cbo.gov/system/files/2023-05/51301-2023-05-medicaid.pdf; Child. Health Ins. Program, Cong. Budget office Baseline Projections (2023), https://www.cbo.gov/system/files/2023-05/51296-2023-05-chip.pdf.

68. Dep’t of Health & Hum. Servs. & Ctr. for Medicare & Medicaid Servs., Medicare & Medicaid Milestones 1937-2015, 3, 7 (2015).

69. Id. at 2–3.

70. Diane Rowland & Barbara Lyons, Medicare, Medicaid, and the Elderly Poor, 18 Health Care Fin. Rev. 61, 66 (1996).

71. Meredith Freed et al. Medicare Advantage in 2023: Enrollment Update and Key Trends. Kaiser Fam. Found. (Aug. 9, 2023), https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-enrollment-update-and-key-trends/.

72. Jennifer Tolbert et al., Key Facts about the Uninsured Population, Kaiser Fam. Found. (Dec. 19, 2022), https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.

73. Robin A. Cohen & Amy E. Cha, Ctrs. for Disease Control and Prevention, Health Insurance Coverage: Estimates from the National Health Interview Survey, 2022 6 (2023), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202305_1.pdf.

74. Olena Mazurenko et al., The Effects of Medicaid Expansion under the ACA: A Systematic Review, 37 Health Aff. 944, 946 (June 2018), https://www.healthaffairs.org/doi/epdf/10.1377/hlthaff.2017.1491.

75. Medicaid Providers, Tex. Health and Human Servs., https://www.hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program/medicaid-providers (last visited Dec. 21, 2023).

76. See Robert I. Field, Mother of Invention: How the Government Created “Free-Market” Health Care 24 (2014); David Dranove et al., The Commonwealth Fund, The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal 2 (2017), https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2017_may_dranove_aca_medicaid_expansion_hospital_uncomp_care_ib.pdf.

77. Dranove et al., supra note 76, at 3.

78. Mazurenko et al., supra note 74, at 948.

79. Elizabeth Williams & Mary Beth Musumeci, The Intersection of Medicaid, Special Education Service Delivery, and the COVID-19 Pandemic, Kaiser Fam. Found. (Jan. 21, 2022), https://www.kff.org/medicaid/issue-brief/the-intersection-of-medicaid-special-education-service-delivery-and-the-covid-19-pandemic/; see also Benefits, Medicaid.gov, https://www.medicaid.gov/medicaid/benefits/index.html (last visited Dec. 24, 2023).

80. Medicaid’s Role in Nursing Home Care, Kaiser Fam. Found. (June 20, 2017), https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/.

81. Thomas C. Buchmueller et al., JAMA Health F., The Benefits of Medicaid Expansion 1 (2020), https://jamanetwork.com/journals/jama-health-forum/fullarticle/2768596.

82. Medicaid Disproportionate Share Hospital (DHS) Payments, Medicaid.gov, https://www.medicaid.gov/medicaid/financial-management/medicaid-disproportionate-share-hospital-dsh-payments/index.html (last visited Dec. 24, 2023). DSH supplements are also paid to hospitals by Medicare. Id. State Medicaid programs are required by federal law to make these payments. Social Security Act § 1902, 42 U.S.C. § 1396(a).

83. Off. of the Assistant Sec’y for Planning and Evaluation, Analysis of the Joint Distribution of Disproportionate Share Hospital Payments (2002), https://aspe.hhs.gov/reports/analysis-joint-distribution-disproportionate-share-hospital-payments-0.

84. Fact Sheet: Medicaid DSH Program. Am. Hosp. Ass’n. May 2023, https://www.aha.org/fact-sheets/2023-03-28-fact-sheet-medicaid-dsh-program (last visited Dec. 21, 2023).

85. Medicaid Disproportionate Share Hospital Payments, Cong. Rsch Serv. (2023), available at https://crsreports.congress.gov/product/pdf/R/R42865.

86. See generally Lindsay Shea & Robert I. Field, Medicaid Coverage for Autistic Individuals: Coverage, Gaps, and Research Needs, 13 Drexel L. Rev.961, 961-985 (2021).

87. See Mira Norton et al., Medicare and Medicaid at 50, fig.1, Kaiser Fam. Found. (July 17, 2015), https://www.kff.org/medicaid/poll-finding/medicare-and-medicaid-at-50/. In contrast to Medicaid, Medicare is perennially one of the most popular insurance programs in the United States. See id. In a poll conducted in 2015 by the Kaiser Family Foundation, 77% of respondents felt that Medicare was a “very important” program compared to 63% who felt that way about Medicaid. Id.

88. See Trudy Lieberman, Medicaid still a target of health care reform, Chicago Tribune, https://www.chicagotribune.com/suburbs/post-tribune/opinion/ct-ptb-lieberman-health-column-st-1005-20171004-story.html (Oct. 4, 2017, 4:20 PM).

89. Status of State Medicaid Expansion Decisions: Interactive Map, Kaiser Fam. Found. (Dec. 1, 2023), https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ [hereinafter Interactive Map].

90. See Why Does the Medicaid Debate Matter? National Data and Voices of People with Medicaid Highlight Medicaid’s Role, Kaiser Fam. Found. (June 19, 2017), https://www.kff.org/medicaid/fact-sheet/why-does-the-medicaid-debate-matter-national-data-and-voices-of-people-with-medicaid-highlight-medicaids-role/.

91. Christie Provost & Paul Hughes, Medicaid: 35 Years of Service, 22(1) Health Care Fin. Rev. 141, 141-174 (2000).

92. 42 U.S.C. § 1315.

93. Elizabeth Hinton et al., Kaiser Fam. Found., 3 Key Questions: Section 1115 Medicaid Demonstration Waivers 4 (2017), https://files.kff.org/attachment/Issue-Brief-3-Key-Questions-Section-1115-Medicaid-Demonstration-Waivers.

94. Alice Burns et al., Ending the Public Health Emergency for Medicaid Home and Community-Based Services, Kaiser Fam. Found. (Apr. 19, 2023), https://www.kff.org/policy-watch/ending-the-public-health-emergency-for-medicaid-home-and-community-based-services/.

95. 42 U.S.C. § 1396n.

96. 42 U.S.C. § 18052 (2012); Waivers for State Innovation, 80 Fed. Reg. 78,131, 78,131 (Dec. 16, 2015) (to be codified at 45 pt. 33) (implementing regulations were published at Department of Health and Human Services); see generally Heather Howard & Galen Benshoof, Health Affairs Blog Post: 1332 Waivers and the Future of State Health Reform, 15 YALE J. health pol l. & ethics 237, 237-8 (2015).

97. See Home and Community Based Services, Medicaid.gov, https://www.medicaid.gov/medicaid/home-community-based-services/index.html (last visited Dec. 21, 2023).

98. See 42 U.S.C. § 1396n(c)(1).

99. Home and Community Based Services, supra note 97.

100. Medicaid Waiver, Autism Soc’y of Indiana, https://www.autismsocietyofindiana.org/programs/medicaid-waiver/ (last visited Dec. 21, 2023).

101. See Adult Autism Waiver, Dep’t of hum. servs., https://www.dhs.pa.gov/Services‌/Disabilities-Aging/Pages/Adult Autism Waiver.aspx (last visited Mar. 27, 2021).

102. 42 U.S.C. § 1396d(r).

103. See Cindy Mann, Ctrs. for Medicaire & Medicaid Servs., Clarification of Medicaid Coverage of Services to Children with Autism 5 (2014), https://californiahealthline.org/wp-content/uploads/sites/3/2016/01/cms-guidance-on-autism.pdf.

104. Disability Services & Waivers, MedicaidWaiver.org, http://www.medicaidwaiver.org/ (last visited Mar. 27, 2021).

105. Diana L. Velott et al., Medicaid 1915(c) Home- and Community Based Services Waivers for Children with Autism Spectrum Disorder, 20 Autism 473, 475 (2015).

106. See Rafael M. Semansky et al., Medicaid’s Increasing Role in Treating Youths with Autism Spectrum Disorders, 62 Psychiatric Servs. 588, 588 (2011).

107. Douglas L. Leslie et al., The Effects of Medicaid Home and Community-Based Services Waivers on Unmet Needs Among Children with Autism Spectrum Disorder, 55 Med. Care 57, 63 (2017).

108. See Douglas L. Leslie et al., Medicaid Waivers Targeting Children with Autism Spectrum Disorder Reduce the Need for Parents to Stop Working, 36 Health Aff. 282, 287 (2017).

109. See Lindsay L. Shea et al., Transition-Age Medicaid Coverage for Adolescents with Autism and Adolescents with Intellectual Disability, 124 Am. J. Intell. Dev. Disability 174, 175 (2019), https://meridian.allenpress.com/ajidd/article-abstract/124/2/174/73278/Transition-Age-Medicaid-Coverage-for-Adolescents?redirectedFrom=fulltext.; see also Whitney Schott et al., Autism Grows Up: Medicaid’s Role in Serving Adults on the Spectrum, 72 Psychiatric Servs. 597, 597 (published online ahead of print Sept. 29, 2020), https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202000144.

110. CARES Act, Pub. L. 116-136, 134 Stat. 281 (2020); What’s in the $2 Trillion Coronavirus Relief Package?, Comm. for a Responsible Fed. Budget (Mar. 25, 2020), https://www.crfb.org/blogs/whats-2-trillion-coronavirus-relief-package.

111. Gideon Lukens et al., Covid Relief Provisions Stabilized Health Coverage, Improved Access and Affordability, Ctr. for Budget and Pol’y. Priorities (Mar. 10, 2022), https://www.cbpp.org/research/health/covid-relief-provisions-stabilized-health-coverage-improved-access-and.

112. Id.; see also Julia E. Smith et al., As Medicaid Continuous Coverage Requirements Ends, Randomized Controlled Trials Can Minimize Churn, Health Aff. Forefront (Sept. 27, 2022), https://www.healthaffairs.org/content/forefront/medicaid-continuous-coverage-requirement-ends-randomized-controlled-trials-can-minimize?utm_medium=email&utm_source=hat&utm_campaign=forefront&utm_content=september+2022&vgo_ee=FtsI2cOeEZHV8mCjs2AEmSHwbBewXoFoJ7RVE%2FWOt94%3D.

113. Rachel Dolan & Samantha Artiga, State Actions to Facilitate Access to Medicaid and CHIP Coverage in Response to COVID-19, Kaiser Fam. Found. (May. 22, 2020), https://www.kff.org/coronavirus-covid-19/issue-brief/state-actions-to-facilitate-access-to-medicaid-and-chip-coverage-in-response-to-covid-19/.

114. Id. In addition, the American Rescue Plan Act, Pub. L. 117-2, 135 Stat. 4 (2021) added incentives for states to offer additional Medicaid benefits. See MaryBeth Musumeci, Medicaid Provisions in the American Rescue Plan Act, Kaiser Fam. Found. (Mar. 18, 2021), https://www.kff.org/medicaid/issue-brief/medicaid-provisions-in-the-american-rescue-plan-act/.

115. Bradley Corallo & Sophia Moreno, Analysis of Recent National Trends in Medicaid and CHIP Enrollment, Kaiser Fam. Found. (Apr. 4, 2023), https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/.

116. See Medicaid Eligibility, supra note 4.

117. Jennifer Wagner & Judith Solomon, Continuous Eligibility Keeps People Insured and Reduces Costs, Ctr. on Budget and Pol’y Priorities (May 4, 2021), https://www.cbpp.org/research/health/continuous-eligibility-keeps-people-insured-and-reduces-costs.

118. Id.

119. Medicaid EPSDT, Autism Speaks, https://www.autismspeaks.org/medicaid-epsdt (Feb. 2022).

120. Ctrs. for Medicare & Medicaid Servs., Medicare and Medicaid Basics 1 (2018), https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProgramBasicsText-Only.pdf.

121. See Medicaid Eligibility, supra note 4.

122. See Administration, Medicaid and CHIP Payment and Access Comm’n., https://www.macpac.gov/medicaid-101/administration/ (last visited Oct. 18, 2023).

123. Medicaid Program; Face-to Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health, 81 Fed. Reg. 5,529, 5,530 (Feb. 2, 2016).

124. Immigrants’ Experience with Medicaid Enrollment: Challenges and Recommendations, Immigration Rsch. Initiative (Mar. 30, 2022), https://immresearch.org/publications/immigrants-experience-with-medicaid-enrollment/.

125. Noelle Cornelio et al., Increasing Medicaid’s Stagnant Asset Test for People Eligibility for Medicare and Medicaid Will Help Vulnerable Seniors, 40 Health Aff. 1943, 1943 (2021), https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.00841?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub 0pubmed/.

126. Id. at 1943-44.

127. See Jennifer P. Stuber et al., The George Washington Univ. Sch. of Pub. Health and Health Servs., Beyond Stigma: What Barriers Actually Affect the Decisions of Low-Income Families to Enroll in Medicaid 3 (2000), https://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1052&context=sphhs_policy_briefs; see also Donald P. Moynihan et al., Policymaking by Other Means: Do States Use Administrative Barriers to Limit Access to Medicaid? 48 Admin & Soc 497, 497 (2016).

128. Jocelyn M. Wilson et al., Are State Medicaid Application Enrollment Forms Readable?, 20 J. of Health Care for the Poor and Uninsured 423, 423 (2009).

129. Donna Cohen Ross, New Medicaid Citizenship Document Requirement is Taking a Toll: State Enrollment is Down and Administrative Costs are Up, Ctr. on Budget and Pol’y. Priorities (Mar. 13, 2007), https://www.cbpp.org/research/new-medicaid-citizenship-documentation-requirement-is-taking-a-toll-states-report.

130. Madeline Guth & MaryBeth Musumeci, An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations?, Kaiser Fam. Found. (May 3, 2022), https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/.

131. See Ashley M. Fox et al., Administrative Easing: Rule Reduction and Medicaid Enrollment. 80 Public Admin. Rev. 104, 104 (May 18, 2022), https://onlinelibrary.wiley.com/doi/pdf/10.1111/puar.13131?casa_token=2m4YOA0e_EYAAAAA:hBtMkUoBD_hK2zYyiaIPi7t83iYkg0lq9H-L3lO3o1sxOBNAEy6pZggySpB73cnG1oVIs1tfGtJRAK6g.

132. Kim Condon, Pros and Cons of Presumptive Medicaid Eligibility, Midland Group (Sept. 8, 2016), https://www.midlandgroup.com/blog/pros-and-cons-of-presumptive-medicaid-eligibility/.

133. See Kaiser Fam. Found., Citizenship Documentation Requirements in Medicaid (2007), https://www.kff.org/wp-content/uploads/2013/01/7533-02.pdf.

134. Jennifer Wagner & Alicia Huguelet, Opportunities for States to Coordinate Medicaid and SNAP Renewals, Ctr. for Budget and Pol’y Priorities (Feb. 5, 2016), https://www.cbpp.org/research/health/opportunities-for-states-to-coordinate-medicaid-and-snap-renewals. The Center for Budget and Policy Priorities has proposed coordination of eligibility renewals under Medicaid and the Supplemental Nutrition Assistance Program. See id.

135. Continuous Eligibility for Medicaid and CHIP Coverage, Medicaid.gov, https://www.medicaid.gov/medicaid/enrollment-strategies/continuous-eligibility-medicaid-and-chip-coverage/index.html (Sept. 9, 2021).

136. See Mark Shepard & Myles Wagner, Nat. Bureau of Econ. Rsch., Do Ordeals Work for Selection Markets? Evidence from Health Insurance Auto-Enrollment 3-4 (Aug. 2023), https://www.nber.org/system/files/working_papers/w30781/w30781.pdf. In addition, one state, Massachusetts, has experimented with an automatic process that enrolled beneficiaries without insurance in a no-cost government-subsidized policy. See id. at 14.

137. Eligibility and Enrollment Changes Under the ACA, N.Y. State Dep’t of Health, https://www.health.ny.gov/health_care/medicaid/redesign/2013-14_executive_budget_proposal_aca_changes.htm (Feb. 2017).

138. Overview of the Affordable Care Act and Medicaid, supra note 18.

139. 42 C.F.R. § 435.916; 42 C.F.R. § 435.916(C).

140. See e.g. Eligibility and Enrollment Changes Under the ACA, supra note 137.

141. An updated Look at Rates of Churn and Continuous Coverage in Medicaid and CHIP, Medicaid and CHIP Payment Access Comm’n. (Oct. 2021), https://www.macpac.gov/wp-content/uploads/2021/10/An-Updated-Look-at-Rates-of-Churn-and-Continuous-Coverage-in-Medicaid-and-CHIP.pdf.

142. Samantha Artiga & Robin Rudowitz, How is the ACA Impacting Medicaid Enrollment?, Kaiser Family Found. (May 5, 2014), https://www.kff.org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/.

143. See 42 U.S.C. § 1396n(c).

144. See 42 U.S.C.A. § 1396n(b)(8).

145. 42 U.S.C. § 1396a.

146. See, e.g., Ashley M. Fox et al., Trends in State Medicaid Eligibility, Enrollment Rules and Benefits, 39 Health Aff. 1909, 1909-10 (2020).

147. Id. at 1911-12.

148. Id. at 1913.

149. Id.

150. Benjamin D. Sommers et al., Reasons for the Wide Variation in Medicaid Participation Rates Among States Hold Lessons for Coverage Expansion in 2014, 31 Health Aff. 909, 914 (2012).

151. Id.

152. Id. at 912.

153. See id. at 912-13.

154. Id. at 913.

155. Moynihan et al., supra note 127, at 509.

156. Pamela Herd & Donald Moynihan, Health Aff., How Administrative Burdens can Harm Health 1-2 (2020).

157. Id. at 2.

158. Jessica Greene & Diane Gibson, Medicaid at 57: Still Essential and Needs Improvement as COVID-19 Emergency Unwinding Looms, Health Aff. (Sept. 29, 2022), https://www.healthaffairs.org/do/10.1377/forefront.20220927.41421.

159. Id.

160. Id.

161. Id.

162. Id.

163. Id.

164. Greene & Gibson, supra note 158.

165. Moynihan et al., supra note 127, at 518-19.

166. Id. at 516.

167. Id. at 500.

168. Id.

169. Id. at 518.

170. See Guth & Musumeci, supra note 130, at Figure 1.

171. Id.

172. MaryBeth Musumeci, Kaiser Fam. Found., Medicaid and Work Requirements 2 (2017), https://files.kff.org/attachment/Issue-Brief-Medicaid-Enrollees-and-Work-Requirements.

173. Id. at 5-6.

174. A Snapshot of State Proposals to Implement Medicaid Work Requirements Nationwide, Nat’l Acad. for State Health Pol’y (Aug. 24, 2021), https://nashp.org/a-snapshot-of-state-proposals-to-implement-medicaid-work-requirements-nationwide/.

175. Id.

176. Id.

177. Jennifer A. Staman, Medicaid Work Requirements: An End to the Litigation? 1 Cong. Research Service (March 12, 2021), https://crsreports.congress.gov/product/pdf/LSB/LSB10577,

178. Robin Rudowitz et al., February State Data for Medicaid Work Requirements in Arkansas, Kaiser Fam. Found. (Mar. 25, 2019), https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/.

179. Gresham v. Azar, 363 F.Supp.3d 165 (D.D.C. 2019) aff’d. 950 F.3d 93 (D.C. Cir. 2020).

180. Benjamin D. Sommers et al., Medicaid Work Requirements – Results From the First Year in Arkansas, 381 N. Engl. J. Med. 1073, 1073 (2019).

181. Id.

182. Id.

183. Id.

184. Laura Harker, Pain But No Gain: Arkansas’ Failed Medicaid Work – Reporting Requirements Should Not Be a Model, Ctr. on Budget and Policy Priorities (Aug. 8, 2023), https://www.cbpp.org/research/health/pain-but-no-gain-arkansas-failed-medicaid-work-reporting-requirements-should-not-be#:~:text=Reporting a month’s hours had,or online at any time.

185. Rudowitz et al., supra note 178.

186. Sommers et al., supra note 180.

187. Id.

188. Id.

189. Id.

190. Rudowitz et al., supra note 178.

191. Id.

192. Rachel Garfield et al., Implications Of A Medicaid Work Requirement: National Estimates Of Potential Coverage Losses, Kaiser Family Found. (June 27, 2018), https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/.

193. Id.

194. Tia Ivey, How Georgia’s New Medicaid Work Requirement Program Will Work, Morgan County Citizen (Dec. 27, 2022), https://www.morgancountycitizen.com/news/how-georgia-s-new-medicaid-work-requirement-program-will-work/article_f0ca28ba-8592-11ed-86c3-c77227bc52af.html.

195. Rudowitz et al., supra note 178.

196. Id.

197. Robert King, Judge Rules CMS Unfairly Overturned Georgia’s Medicaid Work Requirements Program, Fierce Healthcare (Aug. 22, 2022, 4:00 PM), https://www.fiercehealthcare.com/payers/judge-rules-cms-unfairly-overturned-gas-medicaid-work-requirements-program.

198. See Ivey, supra note 194.

199. Jeff Lagasse, Federal Judge Reinstates Georgia Medicaid Work Requirements. Healthcare Finance (Aug. 23, 2022), https://www.healthcarefinancenews.com/news/federal-judge-reinstates-georgia-medicaid-work-requirements.

200. Georgia v. Lasure, No. 2:22-CV-6 (S.D. Ga. Aug. 19, 2022).

201. Id.

202. Id.

203. Interactive Map, supra note 89.

204. Lagasse, supra note 199.

205. Ivey, supra note 194.

206. Lagasse, supra note 199.

207. Ivey, supra note 194.

208. See id.

209. See id.

210. Id.

211. Aditi Vasan et al., Association of WIC Participation and Electronic Benefits Transfer Implementation, 175 JAMA Pediatrics 609, 613 (2021).

212. Frederic Blavin et al., The Effects of Express Land Edibility on Medicaid and CHIP Enrollment Among Children, 49 Health Serv. Res. 1268, 1280 (2014).

213. Adrianna McIntyre & Mark Shepard, Automatic Insurance Policies – Important Tools for Preventing Coverage Loss, 386 N. Engl. j. Med. 408, 409 (2022); see also Shepard & Wagner, supra note 136, at 3.

214. Id. at 409-10. The effort in Massachusetts, to switch people to a zero-premium Marketplace plan when they fell behind on premiums in their existing plan reduced coverage loss by 14%. Id. at 410.

215. Fox et al., supra note 131, at 104.

216. Id. at 113.

217. Id. at 104.

218. Id. at 106.

219. Id. at 104.

220. Leighton Ku et al., Continuous-Eligibility Policies Stabilize Medicaid Coverage for Children and Could Be Extended to Adults with Similar Results, 32 Health Aff. 1576, 1578 (2013).

221. Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3, 123 Stat. 8 (2009); Ku et al., supra note 220, at 1576.

222. Ku et al., supra note 220, at 1576.

223. Elizabeth Williams et al., Implications of Continuous Eligibility Policies for Children’s Medicaid Enrollment Churn, Kaiser Fam. Found. (Dec. 21, 2022), https://www.kff.org/medicaid/issue-brief/implications-of-continuous-eligibility-policies-for-childrens-medicaid-enrollment-churn/.

224. Sherry Glied & Katherine Swartz, Stopping the “Medicaid Churn” – Addressing Medicaid Coverage After the COVID-19 Public Health Emergency Ends, 3 JAMA Health F. 2 (2022), https://jamanetwork.com/journals/jama-health-forum/fullarticle/2798330.

225. Id.

226. Id.

227. Id.

228. Cynthia Shirk, Nat’l Health Pol’y F., Medicaid and Mental Health Services 3 (2008).

229. Benjamin D. Sommers, From Medicaid to Uninsured: Drop-Out Among Children in Public Insurance Programs, 40 Health Servs. Res. 59, 60, 66-67 (2005), https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1475-6773.2005.00342.x?casa_token=vF2lTYRFJzMAAAAA:99URj3Vhs4hPazgFwnAyOf1epfS4WAKUABehOb1cyotTYGUaKRGdPIE5DlvDSlToifx0FANYAq6CS4EP.

230. Id. at 59.

231. Id.

232. Shea et al., supra note 109, at 181.

233. Id. at 178-81.

234. Id. at 181.

235. Michael D. Pullman et al., Patterns of Medicaid Disenrollment for Youth with Mental Health Problems, 67 Med. Care Rsch. & Rev. 657, 670 (2010), https://journals.sagepub.com/doi/10.1177/1077558710369911. More women than men were found to regain Medicaid coverage, with almost one-third qualifying because of pregnancy. Id. at 665. Regaining coverage through Social Security income or a diagnosis of developmental disabilities was found to be more common than through poverty. Id. at 670.

236. Gerry Lynn Fairbrother et al., How Stable is Medicaid Coverage for Children?, 26 Health Aff. 520, 524 (2007), https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.26.2.520?casa_token=ICIdBg2xsnAAAAAA%3AYtGzCq2NEhPBiBOdAod5Qt_8oNv4rWWyQS5WuN2TOlURH1MKpwNnSi87erRtmLjKKzfe5Xowxfwc.

237. Anthony Goudie & Adam C. Carle, Ohio Study Shows That Insurance Coverage is Critical for Children with Special Health Care Needs as They Transition to Adulthood, 30 Health Aff. 2382, 2382 (2011), https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2011.0641?casa_token=SMrVCB-u3VwAAAAA%3AEb5mQBN_PMQhTPvYBBjuNE7mwzGFHO4pqho72oN3HW1r6-8lAeJopCnKFw7KPKwaLbvk-FdMdd2J.

238. Id.

239. While the law ended the PHE and necessitates redeterminations of Medicaid eligibility by states, it also imposes transparency obligations. See Farah Erzouki, Ctr. on Budget & Pol’y Priorities, States Must Act to Preserve Medicaid Coverage as End of Continuous Coverage Requirement Nears 4 (Feb. 6, 2023). States must report on a monthly basis to CMS a number of metrics, including renewals completed ex parte without submission of a renewal form, coverage terminations for procedural reasons, and call center performance in terms of volume, wait times, and abandonment rates. Id. at 2.

240. Ctrs. for Medicare & Medicaid Servs., Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) upon Conclusion of the COVID-19 Public Health Emergency 3-4 (2022), https://www.medicaid.gov/federal-policy-guidance/downloads/sho22001.pdf (guidance for state officials).

241. See Joyce Frieden, Medicaid Won’t Look the Same After the COVID Public Health Emergency Ends, MedPage Today (Oct. 25, 2022), https://www.medpagetoday.com/publichealthpolicy/medicaid/101420.

242. Jennifer Tolbert & Maghana Ammula, 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Requirement, Kaiser Fam. Found. (June 9, 2023), https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-requirement/ (explaining that 46 states allow individuals to submit information over the phone).

243. Id.

244. Id.

245. Id.; Tricia Brooks et al. Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepared for the Unwinding of the Pandemic-Era Continuous Enrollment Provision. Kaiser Fam. Found. (Apr. 4, 2023), https://www.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-and-renewal-policies-as-states-prepare-for-the-unwinding-of-the-pandemic-era-continuous-enrollment-provision-report/ (“State strategies include approving overtime (30 states) and hiring new staff (26 states), temporary workers (13 states), or contractors (16 states), and bringing back retirees (14 states, Figure 3).”)

246. Robert King, States expect up to a year to finish Medicaid redeterminations after COVID-19 emergency ends, Fierce Healthcare (Sept. 16, 2022, 8:25 AM), https://www.fiercehealthcare.com/payers/states-expect-year-finish-medicaid-redeterminations-after-covid-19-emergency-ends?oly_enc_id=4568G1081334I1I.

247. Id.

248. Id.

249. See Robert King. CMS Clears Medicaid Coverage Expansions and Bid to Close Equity Gaps in Massachusetts, Oregon, Fierce Healthcare (Sept. 28, 2022), https://www.fiercehealthcare.com/payers/cms-clears-medicaid-coverage-expansions-and-bid-close-equity-gaps-mass-oregon.

250. Id.

251. See Galewitz, supra note 32. Washington State has sought approval from CMS for a similar plan, New Mexico is considering such a plan, and California is seeking approval for a plan to keep children enrolled until age five. Id.

252. Id.

253. King, supra note 249.

254. Id.

255. Medicaid Enrollment and Unwinding Tracker, Kaiser Fam. Found. (Dec. 20, 2023), https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/?_hsmi=274164629&_hsenc=p2ANqtz-9E9pTV_54IuW2pMyp9RVmROneCg0wpeJde4qetvHyF6VI8D1ehnd_tSoOecO1me_sa9p9TSEjCuZz0mGxsWtNDnJePCQ (source is subject to regular updating).

256. Id.

257. Matthew Buettgens & Andrew Green, Urb. Inst., What Will Happen to Medicaid Enrollees’ Health Coverage After the Public Health Emergency? 2 (2022), https://www.urban.org/research/publication/what-will-happen-medicaid-enrollees-health-coverage-after-public-health-emergency. The Kaiser Family Foundation has estimated that total disenrollments could be between eight and twenty-four million. Tolbert & Ammula, supra note 242.

258. Off. of Health Pol’y, Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches 1, (2022), https://aspe.hhs.gov/sites/default/files/documents/60f0ac74ee06eb578d30b0f39ac94323/aspe-end-mcaid-continuous-coverage.pdf; see also Tricia Brooks, An Estimated 3.8 Million Eligible Children Could Lose Medicaid Due to Administrative Churn During the Unwinding, Georgetown Univ. Health Pol’y Inst. (Aug. 22, 2022), https://ccf.georgetown.edu/2022/08/22/millions-of-eligible-children-could-lose-medicaid-due-to-administrative-churn-during-the-unwinding/.

259. Les Masterson, How Much Does Obamacare Cost in 2023?, Forbes Advisor (Sept. 12, 2023, 5:32 AM), https://www.forbes.com/advisor/health-insurance/how-much-is-obamacare/.

260. Tolbert & Ammula, supra note 242. Some of the variation is caused by the use of different approaches to unwinding continuous enrollment. Id. Streamlined procedures can promote continuity of coverage. Id.

261. Medicaid Enrollment and Unwinding Tracker, supra note 255. These figures are reported by the Kaiser Family Foundation, which maintains detailed statistics on state eligibility determinations since the end of the disenrollment moratorium.

262. Id.

263. Id.

264. Id.

265. Id.

266. Tolbert & Ammula, supra note 242.

267. Amaya Diana, Jennifer Tolbert, Robin Rudowitz & Bradley Corallo. Naviating the Uniwinding of Medicaid Continuous Enrollment: A Look at Enrollee Experiences. Kaiser Fam. Found. (Nov. 9, 2023). https://www.kff.org/medicaid/report/navigating-the-unwinding-of-medicaid-continuous-enrollment-a-look-at-enrollee-experiences/. (Reporting that many of those who were disenrollment experienced numerous eommunication problems.)

268. Tolbert & Ammula, supra note 242.

269. Id.

270. Id.

271. Id.

272. Id.

273. Id.

274. Daniel Tsai, Ctrs. for Medicaid & Medicaid Servs. Letter to State Medicaid Director 1, 3-4 (Aug. 30, 2023), https://www.medicaid.gov/sites/default/files/2023-08/state-ltr-ensuring-renewal-compliance.pdf; see also Megan Messerly, Biden Administration Warns States as Millions Lose Medicaid, Politico (Aug. 10, 2023, 6:15 PM), https://www.politico.com/news/2023/08/10/biden-administration-states-medicaid-00110686.

275. Ctrs. for Medicare & Medicaid Servs, Available State Strategies to Minimize Terminations for Procedural Reasons During the COVID-19 Unwinding Period 1-6 (2023), https://www.medicaid.gov/sites/default/files/2023-06/state-strategies-to-prevent-procedural-terminations.pdf.

276. Dept. of Health and Human Servs., Centers for Medicare & Medicaid Services. Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Process. 87 Fed. Reg. 54,760, 54,760 (proposed Sept. 7, 2022) (to be codified at 42 CFR pts. 431, 435, 457, 600). The rules include more than twenty requirements for state administration of both Medicaid and CHIP. See id. Among the most consequential are that states eliminate the requirement that applicants apply for benefits in other programs, that they establish timelines for renewals, and that they increase flexibility in assigning beneficiaries to some eligibility categories. Id. at 54,803, 54,824, 54,800. For elderly and disabled beneficiaries, for whom eligibility does not change with fluctuations in income, states are directed to require renewals no more frequently than once every twelve months, use prepopulated renewal forms, and eliminate face-to-face interviews. Id. at 54,845. For those beneficiaries who are eligible for both Medicaid and CHIP, states are directed to use publicly available data for addresses when beneficiaries move within the state and to provide sufficient time for beneficiaries to submit enrollment documentation. Id. at 54,852.

277. Williams et al., supra note 223.

278. Social Security Act, 42 U.S.C. § 1115.

279. 42 U.S.C. § 18052 (2012).

280. Howard & Benshoof, supra note 96.

281. See Who Should File a Tax Return, Internal Revenue Serv. (Feb. 14, 2023) https://www.irs.gov/filing/individuals/who-should-file.

282. Publication 501 (2022), Dependents, Standard Deduction, and Filing Information, Internal Revenue Serv., https://www.irs.gov/publications/p501#en_US_2021_publink1000270109.

283. See, e.g., Annual Update of the HHS Poverty Guidelines, 86 Fed. Reg. 7,732, 7,733 (Feb. 1, 2021) (In 2021, the FPL for all states except Alaska was $12,880 for an individual and $17,420 for a household with two people).

284. Elizabeth Gravier, Living in These 9 States Means You Don’t Pay Income Tas, But Here’s What to Watch Out For, CNBC, (Mar. 3, 2022), https://www.cnbc.com/select/states-with-no-income-tax/. In addition, many states and cities impose income taxes and require annual filing requirements. Id.

285. See State Tax Forms, Fed. of Tax Admins. (Feb, 21, 2023), https://taxadmin.org/state-tax-forms/.

286. Stan Dorn, et al., Nine in Ten: Using the Tax System to Enroll Eligible, Uninsured Children into Medicaid and SCHIP (Urban Inst. 2009) (proposing a plan involving automatic enrollment based on tax returns).

287. As discussed supra, Massachusetts has implemented a plan that operates in a similar manner. Under it, individuals insured under the state’s ACA exchange are automatically transitioned to a zero-premium plan if they fall behind on premiums. Shepard & Wagner, supra note 136.

288. Blavin et al., supra note 212.

289. See id.

290. See Zoe Neuberger, WIC Coordination With Medicaid and SNAP, Ctr. on Budget & Pol’y Prior. (Oct 1, 2021), https://www.cbpp.org/research/food-assistance/wic-coordination-with-medicaid-and-snap.

291. See Linda Blumberg et al., The Commonwealth Fund, How Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues (2021), https://www.commonwealthfund.org/sites/default/files/2021-06/Blumberg_how_auto_enrollment_can_achieve_near_universal_coverage_r.pdf.

292. See id. at 3-4.

293. Shepard & Wagner, supra note 136.

294. See e.g., HHS Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon, Dep’t of Health & Human Servs. (Sept. 28, 2022), https://www.hhs.gov/about/news/2022/09/28/hhs-approves-groundbreaking-medicaid-initiatives-in-massachusetts-and-oregon.html.

295. Id.

296. Id.

297. Express Lane Eligibility for Medicaid and CHIP Coverage, Medicaid.gov (Aug 6, 2021), https://www.medicaid.gov/medicaid/enrollment-strategies/express-lane-eligibility-medicaid-and-chip-coverage/index.html.

298. Dan Grunebaum, Affordable Care Act Deductibles, Healthcare Insider (June 11, 2021), https://healthcareinsider.com/affordable-care-act-deductibles-367400.

299. Julie Applebee, The Big Squeeze: ACA Health Insurance Has Lots of Customers, Small Networks, NPR (Apr. 5, 2023), https://www.npr.org/sections/health-shots/2023/04/05/1168088923/the-big-squeeze-aca-health-insurance-has-lots-of-customers-small-networks.

300. Rudowitz, et al., supra note 5.

301. Glied & Swartz, supra note 224.

302. Editorial: Health as a Foundation for Society, 397 The Lancet 10268, 1 (Jan. 1, 2021). https://www.thelancet.com/action/showPdf?pii=S0140-6736(20)32751-3. (“The health community should nurture and encourage multilateral partnerships, in which countries share responsibility for each other, as the best way to build strong and just institutions.”)

303. Dayna Bowen Matthew, Justice and the Struggle for the Soul of Medicaid, 13 J. of Health Law & Policy 29, 34 (1997).

304. Trends in Health Care Spending, Am. Med. Ass’n (Mar. 20, 2023), https://www.ama-assn.org/about/research/trends-health-care-spending.